Biological treatment in ankylosing spondylitis in the Nordic countries during 2010-2016: a collaboration between five biological registries.

OBJECTIVES: Large-scale observational cohorts may be used to study the effectiveness and rare side effects of biological disease-modifying anti-rheumatic drugs (bDMARDs) in ankylosing spondylitis (AS), but may be hampered by differences in baseline characteristics and disease activity across countries. We aimed to explore the research infrastructure in the five Nordic countries regarding bDMARD treatment in AS. METHOD: This observational cohort study was based on data from biological registries in Denmark (DANBIO), Sweden (SRQ/ARTIS), Finland (ROB-FIN), Norway (NOR-DMARD), and Iceland (ICEBIO). Data were collected for the years 2010-2016. Registry coverage, registry inventory (patient characteristics, disease activity measures), and national guidelines for bDMARD prescription in AS were described per country. Incident (first line) and prevalent bDMARD use per capita, country, and year were calculated. In AS patients who started first line bDMARDs during 2010-2016 (n = 4392), baseline characteristics and disease activity measures were retrieved. RESULTS: Registry coverage of bDMARD-treated patients ranged from 60% to 95%. All registries included extensive prospectively collected data at patient level. Guidelines regarding choice of first line drug and prescription patterns varied across countries. During the period 2010-2016 prevalent bDMARD use increased (p < 0.001), whereas incident use tended to decrease (p for trend < 0.004), with large national variations (e.g. 2016 incidence: Iceland 10.7/100 000, Finland 1.7/100 000). Baseline characteristics were similar regarding C-reactive protein, but differed for other variables, including the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) (range 3.5-6.3) and Ankylosing Spondylitis Disease Activity Score (ASDAS) (2.7-3.8) (both p < 0.0001). CONCLUSION: Collaboration across the five Nordic biological registries regarding bDMARD use in AS is feasible but national differences in coverage, prescription patterns, and patient characteristics must be taken into account depending on the scientific question.

Prevalence of long term steroid treatment and the frequency of decision making to prevent steroid induced osteoporosis in daily clinical practice.

BACKGROUND: The use of oral corticosteroids (CS) is one of the most common causes of iatrogenic osteoporosis. Recently, therapeutic guidelines dealing with the skeletal complication of CS have been published. OBJECTIVE: To evaluate how CS are used in the community and the frequency of active intervention against corticosteroid induced osteoporosis in daily clinical practice. MATERIAL AND METHODS: After approval by the Committee on Medical Ethics and the Data Protection Commission all prescriptions for CS which were filled by pharmacies in the northeast area of Iceland (population 26,664) during a two year period were collected. Thereafter, clinical information was obtained from medical records at the healthcare centres and from the local hospital. Patients who were taking CS for at least three months a year or for repeated periods (for a total of three months annually) were included in the study. These patients also received a questionnaire about hormone replacement therapy, bisphosphonates, and dietary consumption of calcium and vitamin D. RESULTS: A total of 191 patients were included in the study or 0.7% of the population. Their mean age was 66 years (17-93) and 106/191 (55%) were women. Only 63 (33%) patients had no registered complication due to the treatment, according their medical records. Thirty nine (20%) patients had had an osteoporosis related fracture and 50 (26%) of the patients had presumed CS induced osteoporosis. A total of 52% patients were receiving supplementary vitamin D (fish liver oil) and 37% were taking calcium tablets regularly, while 91% of the patient group were consuming milk products regularly. Only 17 (9%) patients were taking bisphosphonates and 18/81 (22%) of the postmenopausal women were receiving hormone replacement therapy. CONCLUSIONS: Relatively few patients receiving long term treatment with CS are also receiving primary prevention against CS induced osteoporosis, although several patients are taking vitamin D and calcium tablets. Specific treatment against osteoporosis was in most cases instituted secondary to osteoporotic complications. Thus although there are available treatment alternatives against CS induced osteoporosis, the doctors who prescribed CS did not make use of this form of treatment for their patients.

Hypoxanthine, xanthine, and urate in synovial fluid from patients with inflammatory arthritides.

As nucleotide catabolism increases during tissue injury the appearance of purine metabolites in inflamed synovial fluid might be of value in understanding the joint damage in inflammatory arthritides. In this study, therefore, synovial and plasma concentrations of hypoxanthine, xanthine, and urate in 16 patients with rheumatoid arthritis (three with psoriatic arthropathy) were analysed. It was found that their plasma concentrations of hypoxanthine were greater than those of a reference group of healthy subjects. The synovial fluid concentrations of hypoxanthine, xanthine, and urate were higher than corresponding concentrations in plasma. Positive correlations were found between the respective plasma and synovial fluid values of xanthine and urate. These findings indicate a local enhanced purine metabolism in inflamed joint tissue and diffusion of oxypurines from joint cavity to plasma. No relation was found between measured metabolites and disease duration, radiological joint findings, or synovial fluid cells. Except for a weak correlation between plasma urate and serum haptoglobin, measured purine metabolites were not related to laboratory measures of systemic inflammation.

Cutaneous polyarteritis nodosa associated with Crohn's disease. Report and review of the literature.

A 31-year-old white woman with biopsy verified cutaneous polyarteritis nodosa diagnosed in 1981, developed 6 years later recurrent abdominal pains, rectal bleeding and weight loss. Barium enema demonstrated typical changes of Crohn's disease with fistula in the terminal ileum. Her resected ileum showed granulomatous transmural ileitis without vasculitis. Only corticosteroids and cyclophosphamide controlled the cutaneous and the gastrointestinal symptoms until she was treated with sulfasalazine. The association between cutaneous polyarteritis nodosa and Crohn's disease is discussed and the treatment of earlier reported cases is reviewed.